Evaluation of the ED Patient with Abdominal Pain

University of Utah Medical CenterDivision of Emergency Medicine

Medical Student Orientation

A Common Complaint• 4-8% of all ED Visits• Most Common Diagnoses pts > 50

– Cholecystitis (21%)– Nonspecific abdominal pain (16%)– Appendicitis (15%)– SBO (12%)– Everything else (diverticulitis, hernia, cancer, vascular)

• Most Common Diagnoses pts < 50:– Nonspecific Abdominal Pain ( ~40% )– Appendicits (32%)– Cholecystitis (6%)– SBO and Pancreatitis (each ~ 2%)

Key Consideration!

• Extensive differential• Multiple Life-threatening causes

– AAA– Perforation– Obstruction– Ischemia– Ectopic pregnancy

Other Common Diagnoses• Gastroenteritis*• GERD• Cholecystitis• Appendicitis• Obstruction• Constipation*• UTI*• PID**often misdiagnoses in patients w/significant

abdominal pathology

• H&P are key (as usual)-they help guide your workup and whittle down the large ddx

• Labs and Imaging are used to either support/refute your suspected diagnosis – Occasionally, the labs and imaging will help come

up with a diagnosis when the history and exam are not particularly helpful (altered, confused pt)

Abdominal Pain History

• HPI– Onset– Palliates/Provokes– Quality– Radiation– Severity– Time course– Undo (what have they

done to “undo” their pain)

• PMH– PMHx– Surgical Hx– Allergies– Meds– Social Hx

• EtOH

High-Yield Historical Questions.

• How old are you? (Advanced age means increased risk) • Which came first—pain or vomiting? (Pain first is worse [i.e., more likely

to be caused by surgical disease]) • How long have you had the pain? (Pain for less than 48 hours is worse)• Have you ever had abdominal surgery? (Consider obstruction in patients

who report previous abdominal surgery)• Is the pain constant or intermittent? (Constant pain is worse) • Have you ever had this before? (A report of no prior episodes is worse)• Do you have a history of cancer, diverticulosis, pancreatitis, kidney failure,

gallstones, or inflammatory bowel disease? (All are bad)

High-Yield Historical Questions.• Do you have HIV? (Consider occult infection or drug- related pancreatitis) • How much alcohol do you drink per day? (Consider pancreatitis, hepatitis,

or cirrhosis) • Are you pregnant?( Test for pregnancy—consider ectopic pregnancy) • Are you taking antibiotics or steroids? (These may mask infection)• Did the pain start centrally and migrate to the right lower quadrant?

(High specificity for appendicitis)• Do you have a history of vascular or heart disease, hypertension, or atrial

fibrillation? (Consider mesenteric ischemia and abdominal aneurysm)

Physical Exam

• Vitals• Look• Listen• Percussion• Palpation- where tender, rebound or

guarding?• Rectal and Pelvic-as indicated by history and

exam

Rebound tenderness

•81% sensitive, 50% specific for peritonitis

•63-76% sensitive, 56-69% specific for appendicitis

Rectal Exam

• Generally indicated only in those with symptoms referable to the rectal/anal area or suspected GI bleeding, otherwise rarely useful in generalized abdominal pain workup– Prostatitis– GI bleeding: upper or lower– Hemorrhoids– Constipation: possible impaction?– Bloody diarrhea (enteritis)

RUQRUQ LUQLUQ•Gastric/Peptic UlcerGastric/Peptic Ulcer•Biliary DiseaseBiliary Disease•HepatitisHepatitis•PancreatitisPancreatitis•Retrocecal AppendicitisRetrocecal Appendicitis•Renal StoneRenal Stone•PyelonephritisPyelonephritis•MIMI•Pulmonary EmbolusPulmonary Embolus•PneumoniaPneumonia

•Gastric UlcerGastric Ulcer•GastritisGastritis•PancreatitisPancreatitis•Splenic injurySplenic injury•Renal StoneRenal Stone•PyelonephritisPyelonephritis•MIMI•Pulmonary EmbolusPulmonary Embolus•PneumoniaPneumonia

RLQRLQ LLQLLQ•AppendicitisAppendicitis•Ovarian CystOvarian Cyst•MittelschmerzMittelschmerz•PregnancyPregnancy•Tubo-ovarian abscessTubo-ovarian abscess•PIDPID•Ovarian TorsionOvarian Torsion•CystitisCystitis•ProstatitisProstatitis•Ureteral StoneUreteral Stone•Testicular TorsionTesticular Torsion•EpididymitisEpididymitis•DiverticulitisDiverticulitis•AAAAAA

•DiverticulitisDiverticulitis•Ovarian CystOvarian Cyst•MittelschmerzMittelschmerz•PregnancyPregnancy•Tubo-ovarian abscessTubo-ovarian abscess•PIDPID•Ovarian TorsionOvarian Torsion•CystitisCystitis•ProstatitisProstatitis•Ureteral StoneUreteral Stone•Testicular TorsionTesticular Torsion•EpididymitisEpididymitis•AAAAAA

Causes of Abdominal Pain by QuadrantsCauses of Abdominal Pain by Quadrants

Stop and Think

• Differential Diagnosis • Knowing that labs and radiographic studies

will only aid what you already suspect, identify needed treatments and start them empirically as dictated by pt condition

Laboratory Studies

• These will rarely clinch diagnosis– CBC

• Anywhere from 10-60% of patients with surgically proven appendicitis have an initially normal white count

• An elevated white count detects a mere 53% of severe abdominal pathology.

– Electrolyte, Lipase, UA, LFTs– Pregnancy Test!– ECG (especially in elderly)

Radiographic Studies- Plain Film

• Really only helpful in ED for:– Free air (suspected perforation)– Dilated loops of bowel with air fluid levels

(obstruction)– Foreign body

• Free air seen in only 30-50% of bowel perforation

Sigmoid Volvulus

Sigmoid Volvulus

Sigmoid Volvulus

What’s wrong with this picture??

Radiology- Ultrasound

• Excellent for Biliary Tract Disease (very sensitive for Gallstones (90+%)

• AAA- can rapidly assess size at bedside• Ectopic Pregnancy- look for intrauterine yolk sac,

assess adnexa, assess for free fluid• Appendicitis- 75%-90% sensitive (in experienced

hands, best in thin patients)– Not routinely done in this country. May change.

• Pelvic structures, testicles

Gallstones

AAA

Radiology- CT Scan

• Detect Leaking AAA ( in stable patient )• Excellent for Renal Calculi• Evaluate for appendicitis, perforation (free air), diverticulitis, abscess, mesenteric

ischemia, masses, obstructionThe sensitivity and specificity for these vary. Nothing is 100% accurate

• Not a place for unstable patients

Kidney Stones- CT Style

Sigmoid Tumor/Intussusception

Psoas Abscess

Retroperitoneal Abscess

TOA

Abdominal Pain in the Elderly

• “An M&M waiting to happen”– Mortality & misdiagnosis rise exponentially

w/each decade >50 yrs.– Elderly generally considered 65 and older– Approximately 60-70% get admitted, 40-50% go to

the OR and 10% die (this is higher than mortality of acute MI at 6-8%)

– These patients frequently get, and deserve, a full complement of imaging and labs

Case #1- Presentation

• 23 yo female• acute onset LLQ pain 2 hours ago• Constant, no radiation, no N/V/D• No exacerbating, alleviating factors• No vaginal discharge

Case #1 -PMH

• No medical problems• No medications, No allergies• Surg Hx: S/P Elective Abortion 1 year ago• No history of STDs, Sexually Active• LMP 4 weeks ago

Case #1- Exam

• Vitals: P105 R20 T37.7 BP 103/58• Abd: soft, tender LLQ with guarding, no

rebound pain detected• Pelvic: No cervical motion tenderness, L

adnexal tenderness/fullness• Rectal: No masses, guaiac negative

Case #1- Differential Diagnosis

• Ectopic Pregnancy• Ovarian Cyst• Tubo-ovarian abscess• Ovarian Torsion

Case#1- Intervention/Diagnosis

• Pregnancy Test - Negative• IV Fluids - 500 cc bolus ( repeat P 90,

BP110/65 )• U/S- L ovary with absent blood flow, multiple

cysts• Diagnosis: Ovarian Torsion• Disposition: To OR by GYN

Case #2- Presentation

• 47 yo male with sudden onset abd pain• Epigastric pain, vomited x2• Pain 10/10• Better if holds still, worse on car ride into

hospital• Never had pain like this before

Case #2- Past Medical History

• Medical Hx: Arthritis, Chronic Low Back Pain• Surgical Hx: L knee meniscus repair• Meds: No prescribed meds, OTC ibuprofen• Allergies: NKDA• SH: 2 beers/night

Case #2- Exam

• Vitals: P95 R22 T37.4 BP 124/75 O2 100%• Gen: Anxious, Mild distress/diaphoretic,

Remaining still• Abd: Decreased BS, Severe epigastric

tenderness with guarding and rebound• Rectal: Guaiac positive

Case #2- Actions

• Large bore IV x2, Type and Screen, CBC, CMP, Lipase, Fluid bolus,ECG

• Acute Abdominal Series• Orthostatic Vitals

Case #2 - Interventions/Diagnosis

• CXR reveals intra-abdominal free air• Diagnosis: Perforation, likely duodenal or

gastric ulcer• Disposition: To OR for identification and repair

Multiple Life Threatening Causes of Abdominal Pain

• Identify the potential life threatening cause of the following cases.

• Differential diagnosis is large but consider an acute event and test your intuition

Rapid Cases #1

• 25 yo female• Recurrent vomiting, diffuse mild pain• Febrile, dehydrated, tachycardic• H/O Diabetes Mellitus• Diagnosis: DKA

Rapid Cases #2

• Healthy 17 yo male, football player• L shoulder pain, not reproducible on exam• lightheaded, weak• U/S with free intraperitoneal fluid• Diagnosis: Splenic Lac

Rapid Cases #3

• 16 yo female• Nausea, diffuse discomfort starting yesterday• Now worse RLQ• Abd exam: pain RLQ, +guarding• Diagnosis: Appendicitis

31 yo appy

73 yo appy

Rapid Case #4

• 65 yo male• Hx of HTN, Renal Colic x3 episodes• Low back pain- ?new pain• Abd: obese, soft, no masses palpated• U/S shows 7cm AAA

Rapid Case #5

• 56 yo female• H/O Alcoholic Cirrhosis• Diffuse abd pain, gradual onset• Distended abdomen, febrile• U/S: ascites• Peritoneal tap >500 WBC/cc• Spontaneous Bacterial Peritonitis

Rapid Case #6

• 32 yo female, S/P Tubal ligation 2 weeks ago• Gradual onset diffuse pain• N/V/D, fever• Diffusely tender, guarding, + rebound• CXR with free air• Bowel perforation

Free Air

Rapid Case #7

• 82 yo male S/P distant chole, appy• Gradual onset vomiting, nausea, distension• Distended abdomen, increased bowel sounds• KUB: multiple air fluid levels, dilated loops of

small bowel• Small Bowel Obstruction

Small Bowel Obstruction

Rapid Case #8

• 16 yo male• sudden onset lower abd, scrotal pain• No hx of trauma• Tender L testicle to exam• U/S: No vascular flow to L testicle• Acute Testicular Torsion

Rapid Case #9

• 30 yo female, G3P3 IUD in place• LLQ pain, gradually worsening today• No fever, Tender L Adnexa• + UPT• U/S with L Adnexal Gestational Sac• Ectopic Pregnancy

Rapid Case #10

• 4 yo male• Crampy abdominal pain- crying• Tender diffusely to exam, afebrile• Guaiac positive stool• Complete relief with enema• Intussusception

Intussusception

Rapid Case #11

• 23 yo healthy female• Severe lower abdominal pain• Gradual onset, no N/V/D• Abd Tender Bilateral Lower Quadrants• Cervix tender with movement, UPT -• Dx: PID

Rapid Case #12

• 82 yo Female• H/O HTN, A. Fib, CAD, COPD• Acute severe diffuse abd pain• Exam: Soft, minimal tenderness to palpation• Angiography reveals occluded SMA• DX: Mesenteric Ischemia

Rapid Case #13

• 46 yo female, G3P3• Post Prandial Epigastric pain• Exam: Obese, RUQ tender to palpation• U/S: Multiple Gallstones with GB wall

thickening• DX: Acute Cholecystitis

Acute Cholecystitis

Rapid Case #14

• 78 yo male• H/O HTN, DM• Acute onset nausea, diaphoresis, epigastric

discomfort,• Exam: Mild epigastric discomfort to palpation• ECG ST elevation 3mm leads II, III aVF• Dx: Inferior MI

Inferior STEMI

Rapid Case # 15

• 65 yo female• LLQ pain, gradually worsening• Exam: Febrile, Tender LLQ to palpation• Guaiac + stool• CT: Diverticulitis with multiple

microperforations• Dx: Acute Diverticulitis

Do you see the free air?

Rapid Case #16

• 52 yo alcoholic male• Diffuse abd pain, gradually worsening,

vomiting recurrently• Exam: soft abdomen, minimal tenderness• Labs: Increased lipase• Dx: Pancreatitis

Rapid Case #17

• 14 yo healthy male• Acute crampy abd pain past day• Vomiting, Diaphoretic• Exam: Diffuse mildly tender abdomen with

palpable firm mass in R groin• Dx: Incarcerated inguinal hernia

Incarcerated Hernia

Rapid Case #18

• 28 yo post-partum healthy female• Acute R flank pain radiating to groin• Exam: Abd soft, non-tender without CVA

tenderness• UA with 2+ RBC, no WBCs• CT with R Ureteral Calculi• Dx: Renal Colic

Hydronephrosis

Renal Calculus

Hydro-ureter

UVJ Stone

Rapid Case #19

• 72 yo female c/o RUQ pain & cough• PMHx: HTN, COPD on home O2• Vitals: T38.5 HR 105 RR 26 BP 140/90 SpO2

88% on 2L• Physical: dry mucous membranes, decreased

breath sounds, non-tender abdomen• CXR: RLL infiltrate• Diagnosis: RLL pneumonia

Summary

• The Differential Diagnosis of Abdominal Pain is extensive. Large. Massive even.

• You need to identify patterns that place a person at risk for serious causes of their pain and rule out/in those causes

• History and Physical are the key to narrowing the ddx

• Labs and Radiology support/refute your diagnosis

Summary Continued

• Always get Pregnancy Test (doesn’t matter if they are on OCP’s, had a tubal ligation, or swear they can’t be pregnant due to saintly behavior-OK, no, if hysterectomy or elderly)

• If discharging a patient, always alert patient of symptoms they should watch for and when to return

• If dx is “abdominal pain NOS” (unknown etiology), consider f/u, even in ED, for re-evaluation